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1. International Encyclopedia of Rehabilitation
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2. Art Therapy in Rehabilitation
Theresa Van Lith
Ph.D. Candidate
Department of Counselling and Psychological Health
School of Public Health
La Trobe University
Bundoora, Vic, 3086.
tjvanlith@students.latrobe.edu.au
Patricia Fenner
Course Co-ordinator Graduate Diploma of Art Therapy, Lecturer
Department of Counselling and Psychological Health
School of Public Health
La Trobe University
Bundoora, Vic, 3086
Prof Margot Schofield
Professor of Counselling and Psychotherapy
School of Public Health
La Trobe University, Vic 3086
Director of Research - PACFA
Psychotherapy & Counselling Federation of Australia
Introduction
This article aims to define the multiple ways that art therapy is employed in
rehabilitation and how art therapists practice in rehabilitation settings. We describe
the art-based practice continuum to demonstrate the various styles and practices used
in rehabilitation settings. Some key contributions that art therapy can make to
rehabilitation include: sensory experiences, symbolic expression, emotional
expression, life enhancement, cognitive development and social connectedness.
Finally, there is a discussion on the unique qualities of fostering creativity in
rehabilitation and on the importance of the context where art therapy takes place.
Defining Art Therapy in Rehabilitation
Art therapy involves the discovery of new connections, relationships and meanings in
a safe and non-judgmental atmosphere, which in turn provides the client with
alternative perspectives on life and relationships with others. Thus, art therapy can
work in multifaceted ways involving the whole person including sensory-motor,
perceptual, cognitive, emotional, physical, social and spiritual aspects. Growth
through art is seen as a sign of growth through the whole person (Karkou and
Sanderson 2006).
Art therapy is a fluid, adaptable, and evolving field. Although art has always been an
innate part of human civilisation it has only been since the Second World War that it
has been properly recognised for its restorative and transformative qualities (Hogan
2001; Waller 1991). As Jones (2005) clarified, not only are we still discovering the
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3. nature of the arts but, we are also still in the early stages of understanding what art
therapy does, how it does this and why it is effective.
Those who become art therapists have experience in at least one previous field of
knowledge, such as: medicine, psychology, education, visual arts and social work
traditions. It is through this amalgamation of knowledge and theoretical orientation
that art therapists often define their practice with orientations such as,
psychodynamic; humanistic (i.e. phenomenological, gestalt, person centered); psycho-
educational (behavioural, cognitive behavioural, developmental); systemic (family
and group therapy); as well as integrative and eclectic approaches (Jones 2005; Rubin
2001).
Art therapists work in a variety of rehabilitation settings and with a variety of issues
including: mental health problems; learning difficulties, language and communication
difficulties, imprisonment, medical problems, sensory or physical problems, stress,
emotional and/or social problems. Each of these contexts have their own requirements
for rehabilitation and art therapists need to consider what aspects of art therapy can
serve within the rehabilitative process (Jones 2005). Therefore, art therapists define
what they do by the context they are working in. For example, in examining
individuals who survived an Acquired Brain Injury as well as the researcher’s own
life experience, Smith (2007) highlighted how art served as an aid to rehabilitate
sense of self, self-esteem and social skills through group participation and self-
exploration.
Johnson (2008) discussed how art therapy is used in prison settings and identifies this
through four domains of the rehabilitative process: therapeutic, educational, prison
quality of life management and societal (community involvement). He argues that art
therapy is used as a form of rehabilitation that seeks to fulfil the innate desire to be
productive, seek creative autonomy and as an outlet for expression. These qualities of
art appeal to prisoners, just like the general public, and engage them serving as a
platform to reform and reduce re-offending. The recreational nature of art therapy also
serves to reduce boredom, ease mood, as well as build relationships between prisoners
and staff thus promoting a safer and more cooperative environment.
How Art Therapists Practice in Rehabilitation Settings
Overview of Art Therapists’ Practices
In general, art therapists avoid using medical terminology and diagnostic labels with
their clients, as this is seen as questioning and limiting the individuality of the client
and their individual needs. They see that the art therapist’s role is to “prepare the
ground for the process to start and then facilitate the continuation of the process”
(Karkou and Sanderson 2006, p. 54).
The therapeutic dynamic is understood by many therapists through a construct
incorporating the therapist, client and the art work (Schaverien 1990, 2000). This
triangular model is most frequently used by art therapists who value an analytical
approach to understand the non-verbal and verbal interactions taking place within the
therapeutic milieu.
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4. Allen (1995, 2008) suggested that the therapist’s role is not to change, fix, cure or
interpret the art, but, in collaboration with the client, to witness the flow of expression
present in the images and, should the client desire, to discover inherent meaning in or
through art. Thus, transformation occurs through self-direction as a natural unfolding
of the artist’s reality as expressed through the images. The more fully clients come to
know themselves, the more they are able to authentically participate in life and
community as well as develop an ongoing motivation towards recovery.
When the art work is complete the art therapist may assist their client to find words to
describe their art work by asking them for concrete descriptions of what they see
(refer to Betensky 1995, 2001 for variations of this process of inquiry). Spaniol
(2003) suggested that the therapist’s support and respect for the client’s reality is
critical in encouraging the client to talk about their art in their own words and
personal style.
Spaniol (2003) emphasised three fundamental components of the art therapist’s role in
psychosocial rehabilitation, which can be easily applied to other forms of
rehabilitation. The first is authenticity; the therapist fosters deep relationships with
clients that become a model for clients’ relationships with one another. Secondly, the
therapist fosters creativity in the client’s engagement in the arts and understands the
special role that creativity can play in the lives of people with mental illness. Thirdly,
the therapist supports a climate of recovery through their belief that people with
mental illness can build lives of meaning and purpose despite their illnesses.
The Art-Based Practice Continuum
A recent study auditing art-based activities within the psychosocial rehabilitation
sector developed an art-based practice continuum to explain the diverse range of
approaches that were being adopted. They noted an ongoing tension in how art
facilitators and program managers define art therapy, partly due to art therapists
incorporating the practices of community arts, art education or arts/health, as well as
facilitators from other related fields adopting personal growth oriented practices (Van
Lith, Fenner, Schofield, Pawson and Morgan 2009). The modes, context, levels of
structure and aims of the art-based practices employed in these organisations can be
represented along the following continuum (see Diagram 1).
As this model highlights, art therapists embrace visual art qualities as well as
incorporate therapeutic elements depending on the clients’ needs in their process of
rehabilitation. These varied approaches are not necessarily discretely delivered
programs, but provide a range of methods which can be adapted and applied
according to perceived client needs and the facilitators’ training. Although this
continuum relates to psychosocial rehabilitation programs it is applicable to other
rehabilitation settings.
Diagram 1. Art-based Practice Continuum
Art making
individually
Studio art
making
Art making
with
emphasis on
skill
development
and mastery
Program
facilitated
and
structured
art groups
Individual
art making
with a
healing
purpose
Art
psychotherapy
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5. Key Contributions of Art Therapy in Rehabilitation
Art therapy ultimately works in a strengths-based way to assist in rehabilitation
through restoring the self. These will be explained in the following section under the
following headings: sensory experiences, symbolic expression, emotional expression,
life enhancement, cognitive development and social connectedness.
Sensory Experiences
The visual and material qualities of art media and the art work are unique elements to
art therapy. These offer alternatives to other strategies in rehabilitation as they work
through visual, sensual and kinaesthetic experiences. This can often be perceived as
unconventional in rehabilitation settings and consequently easily misunderstood.
Kagin and Lusebrink’s (1978) expressive therapies continuum demonstrates the
commonalities between various art forms and the defining properties of each medium.
The expressive therapies continuum proposes four levels of experience:
kinaesthetic/sensory (action), perceptual/affective (form), cognitive/symbolic
(schema) and creative (see Hinz 2008, for an updated version of the expressive
therapies continuum). Whilst art therapists may use this scale for evaluative and
reflective purposes they remain cautious that a particular quality of a medium is also
dependent upon the individual’s interactive style and development or regression. For
example, clay may be resistive for an experienced potter or regressive for a young
child.
Symbolic Expression
The use of symbolism and its relationship to our unconscious holds an important
place in the history and development of art therapy (Edwards 2004; Rubin 2005;
Schaverien 1990, 2000). Arnheim (1974) maintained that form and subject matter
cannot be separated and states that even simple line expression is symbolic as it
expresses visible meaning. On the other hand, Dissanayake (1992) argued that the
creation of art alone is satisfying and symbolic meaning may be secondary or absent
in its importance. In art therapy, it is the client’s preference whether they see their
imagery as visual metaphor and this may depend on whether the image developed
inside or outside their conscious awareness. When this type of art is produced in art
therapy, the therapist and client can obtain important information by exploring the
deeper meanings. It is often seen as particularly useful in exploring dreams, goals and
aspirations (Kaplan 2000).
Emotional Expression
Art therapy can serve as a means of symbolic speech, which is particularly beneficial
for clients who have a good mastery of verbal communication or words, but are
unable to accurately express their emotions (Liebmann 1990). For example, for clients
who have limited verbal expression or those who are highly articulate but have
difficulty with emotional expression, the visual arts can be employed as a means of
speaking from the self. When possible a combination of verbal and non-verbal
communication is encouraged as a way of acquiring new and more comprehensive
understandings of what is being expressed to uncover the significance of personal
meanings (Kaplan 2000; Karkou and Sanderson 2006).
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6. Some art therapists embrace the notion that art taps into the unconscious, which
allows thoughts and feelings to be expressed that may otherwise be restrained or
denied (Rubin 2005; Malchiodi 1998). Kaplan (2000) concurs with this by
highlighting that art therapy provides access to our personal and cultural history that
would not be available through verbal means. Utilising this capacity to access
awareness and communicate meaning through art can serve as an alternative to verbal
interventions. Additionally, it has been argued that art is a less threatening method to
disclose private information about one’s feelings, allowing for a deep, thorough and
yet contained exploration of the self (Tate and Longo 2002).
Art therapy also allows for the release of emotions in a contained way, referred to as
catharsis. It provides access to and relief of painful or troubled emotions in a safe and
therapeutic setting by creating a physiological response of relaxation or through
altering mood. This act can result in feelings of empowerment as well as the
experience of inner peace through art expression (Rubin 2005).
A study of art made in concentration camps during the Holocaust potentially
illuminates our understanding further. Ornstein (2006) explained how prisoners
instinctively used art to make sense of their traumatic experience and gain an insight
into their experiences that would otherwise not have been available to them. She
noted the overwhelming need to create in order to transform these experiences into
expression. The image in these situations worked as a mirror of the internal world and
had a confirming and supportive effect, resulting in a feeling of being understood.
Life Enhancement
The making of art is known to induce the experience of flow as a form of optimal
experience producing quality of life enhancement through feelings of psychological
growth, enhanced life quality and well being (Csikszentmihalyi 1990, 1996). Being in
a ‘flow’ state through art therapy enables escapism, distraction and time out from
reality, which are highly beneficial for people with ongoing mental health difficulties
such as anxiety, hallucinations, delusions or for those who are highly stressed
(Warren 2006). Research has also found that by being in a meditative-like state
through the art process, clients are not only able to deal with highly traumatic
material, but the resolving of these issues in imagery allows for insight and personal
growth (Van Lith Fenner and Schofield 2009).
Dissanayake (1988) also emphasised the life altering qualities by arguing that similar
to ritual and play, it enables us to imagine, fantasise, formalise and distance material
as well as provide cathartic relief to tensions. She highlights that it is not just the
‘thoughtless’ experience that is desirable but our direct connection to the immediacy
of art that restores the significance, value and integrity of sensuality and the emotional
power of things. This is seen as a stark contrast to the usual indifference we are used
to experiencing. This heightens our awareness making us more aware of who we are
and what we want.
Dissanayake (1988) also highlighted how art assists in developing resilience as it
prepares and trains us for the unfamiliar through the testing of realities. These
experiences provide a reservoir from which to draw appropriate responses to
experiences that have not yet been met, providing us with the strength to face new
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7. challenges. She adds that through the use of fantasy and imagination art also allows us
to constantly stretch our minds and be challenged in new ways.
Cognitive Development
Our earliest human experiences are believed to be in aural and visual forms, prior to
the development of verbal skills (Golomb 2004). The development and use of these
capacities are often ignored or undervalued as we engage in a predominantly verbal
society. Consequently, art therapist Kaplan (2000) argued the importance for children
to be offered art to enhance and develop well-rounded cognitive skills that not only
activates mind-brain development, but enhances creative abilities through imagination
and play.
Kaplan (2000) also highlighted how art therapy facilitates problem solving. The
distance that the art work provides allows clients to order, reflect, experiment and
refine thoughts and experiences. Kaplan emphasises the importance of using art
therapy for people with cognitive impairments due to its ability to evoke sensual
pleasure and feelings of satisfaction. The importance of promoting sensory
stimulation through art therapy with acquired brain injury clients has been noted.
Sensory stimulation through art therapy enhances clients’ awareness and attention
span as well as provides a new focus through the appreciation and exploration of
materials (Chantios 2005). In certain cases, as a person’s cognitive impairment may
decline, artistic abilities may increase and serve as compensation (Mell Howard and
Miller 2003).
Social Connectedness
The stigma associated with some illnesses such as mental illness, has been identified
as a key barrier to gaining employment, education, feeling like a contributing member
of a community and a sense of social inclusion. In the United Kingdom, researchers
have argued for the importance of maintaining and improving art-based community
organisations as a solution to social exclusion (Moriarty 2002; Secker Hacking
Spandler Kent and Shenton, 2007; Smith 2003; White and Angus 2003).
Parr’s study (2005) focused on how art-based community groups play an important
role in developing social relationships and identity beyond that of stigmatised labels.
The art group was valued as an important ‘stepping stone’ for reintegrating into wider
social relationships and situations outside project spaces. Not only was the art group
seen as a way to work through everyday difficulties, but it was also seen as a form of
self validation whereby participants were able to express without feeling the risk of
interpretation by others. In accordance with this study, Van Lith, Fenner, and
Schofield (2009) also identified how the making of art with those who have chronic
mental health problems can have benefits beyond the internal self, which generates
passion and meaning in life. They also highlighted the importance of making art
within a group setting as this enabled clients to develop a sense of being part of a
social world and a deepening of interpersonal relationships.
Importance of a Supportive Setting in Art Therapy
Art therapists highlight the value of art as having healing or therapeutic potential
through the context of where it takes place. They see art therapy as a process that,
given the circumstances surrounding its use, may become a powerful and life
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8. changing experience (Karkou and Sanderson 2006). The art therapy setting enables
artistic expression by being safe, comfortable and empathic, which is contained by
well-trained and supportive staff. This environment allows for a culture of openness,
empowerment and experimentation to develop (Higgins and Newrith 1999; Waller
1991). A conscious effort from the art therapist is needed to provide and maintain a
supportive psychological and physical environment within which safety and trust are
engendered and nurtured, one that permits an optimal process of creativity to unfold.
Consequently, it is how the therapy takes place, the environment, the development of
relationships and communication during planning and implementation stages that
encourages success and determines whether or not therapeutic transformation is likely
to occur (Everitt and Hamilton 2003). This is substantiated in a report describing
guidelines for the practice of art psychotherapy with people prone to psychotic states
(Brooker Cullum Gilroy McCombe and Mahony 2006).
Conclusion
This article aimed to inform the reader about some of the key areas that art therapy
contributes to rehabilitation. Through this broad overview it was hoped to clarify why
and how art therapy is used in rehabilitation settings. Art therapy is still in the early
stages of finding suitable research approaches to further understand the qualities of its
practice and benefits, as well as finding appropriate methods to evaluate practices.
Nevertheless, the restorative and transformative benefits of art are gaining
considerable attention in rehabilitation settings and readily being adopted as a
positive, strengths-based and meaningful activity.
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